Community Medical Center Dialysis LLC

“CFC-CARE AT HOME CFR(s): 494.100 This Condition is not met as evidenced by: 44769 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Care at Home. Based on interview and record review, the facility failed to: - Follow their established policy and procedure for providing home dialysis patients access to resources and physician assistance 24 hours/day, 7 days/week for 1 (#1) of 5 sampled patients. This failure resulted in a delay of care for a patient who experienced a cardiac emergency resulting in the placement of a pacemaker. (See V592).”

“H-PT CONSULTATION WITH IDT MEMBERS PRN CFR(s): 494.100(c)(1)(iv) Services include, but are not limited to, the following: (iv) Patient consultation with members of the interdisciplinary team, as needed. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to adequately assess and provide follow-up consultation services for a home peritoneal dialysis (PD) patient who called the facility’s 24/7 PD patient help line with complaints of not feeling well, low blood pressure, and a low heart rate for 1 (#1) of 5 sampled patients. This deficient practice resulted in a delay of care for a patient who experienced a cardiac emergency resulting in the placement of a pacemaker. Findings include: During an interview on 03/11/24 at 9:30 a.m., patient #1 stated he felt “cruddy” over the weekend of 01/20/24, and on Monday, 01/22/24, he called staff member A (the acting PD nurse) and informed her that he wasn’t feeling well. Patient #1 stated he told staff member A his blood pressure was 119/40 and his heart rate was 32. Patient #1 stated staff member A’s response was, “That doesn’t seem right, [Staff member B] might want you to go the ED.” Patient #1 stated staff member A told him she would call [Staff member B] and call patient #1 back. Patient #1 stated he did not receive a call back. Patient #1 stated on Wednesday, 01/24/24, he called his primary care doctor’s office and relayed his complaints, blood pressure and heart rate to the nurse, and he was instructed to get to the ER right away. Patient #1 was seen at the ER and admitted to ICU and scheduled to receive a pacemaker the following day. At approximately 1:00 a.m., patient #1 was told he needed emergency surgery for the installation of a temporary pacemaker because he was too unstable to wait until the following day for the permanent pacemaker to be placed. During a phone interview on 03/11/24 at 3:32 a.m., NF1 stated she was the former PD nurse at the facility. NF1 stated if a patient called her with a blood pressure reading of 110-120 over 40-50’s with no symptoms, she would have the patient come to the facility for an assessment. NF1 further stated if a patient reported that blood pressure and reported they weren’t feeling well, she would have the patient go “straight to the ER” and she would notify the nephrologist after. During an interview on 03/11/24 at 3:50 p.m., staff member A stated patient #1 called her on 01/22/24 and stated he wasn’t feeling well. Staff member A stated patient #1 stated his blood pressure was 110-120 over 40-50’s. She stated patient #1 did not tell her what his heart rate was, and if he had, she would have told him to go to the ER. Staff member A stated she told patient #1 if he was feeling poorly, he should be seen at the ER. She stated, “Again, I told him if you’re feeling poorly go to the ER.” Staff member A stated she called staff member B after the phone call with patient #1, and the call went to voicemail. Staff member A stated she did not leave a message. She stated she, “wished” she had left a voicemail. During an interview on 03/11/24 at 4:57 p.m., staff member B stated he did not receive a call from staff member A with regards to patient #1’s concerns on 01/22/24. Staff member B stated a dialysis patient with a blood pressure of 110-120 over 40-50’s with no symptoms would not necessarily be out of the ordinary. He stated if a patient called with an abnormal blood pressure and reported additional symptoms, more questions should be asked. Staff member B stated he did not know patient #1’s heart rate was 32 until after he found out the patient was admitted to the hospital. A review of patient #1’s medical chart showed a progress note dated 02/13/24, authored by staff member A: “Late Entry. On Mon Jan 22, 2024, Patient called PD on-call phone. This RN answered patients call while traveling for a patient home visit. Patient advised that he wasn’t feeling well. Patient stated that his BP was running low. I requested BP readings. Pt advised that his BP’s had been running 110-120’s systolic and 40-50’s diastolic. I advised that while the diastolic was slightly low, the systolic was in normal range. I asked patient what symptoms he was having, and he stated, “I just feel puny’’. I asked if he felt like he was fluid overloaded. He advised he did net think so. I asked what his weights had been as well as what solutions he had used for tx the night before. He advised that his weights had been regular in the 138 kg range and that he had used green solution bags for his tx. I advised if he was feeling unwell that he should be seen in the ER. I also advised that I would reach out to his nephrologist to see if there was any further guidance. Patient verbalized understanding. Once the call ended, I called his nephrologist. l was forwarded to voicemail and received a text stating he would call me later. I did not respond to text, nor did I send a cortext message as I was driving. I did not receive a follow up call from the physician. The next morning, I was, again, traveling for patient related care. I called nephrologist a second time. I was again, forwarded to voicemail. The next evening, I had a voicemail from patient stating that he was seen in the ER at [Hospital Name] and it was noted he had a low heart rate, and they would be keeping him over night...”[sic] A review of an ED provider note for patient #1, from [Hospital Name], dated 1/24/24, showed: “ ...Triage...The patient, [Patient #1], is a 63 y.o. male who presents with concern for low pulse and lightheadedness for 4 days. ...Vital signs: (first vital signs): ...Pulse: (!) 42[sic] Resp: 16 SpO2: 95 % BP: 159/52...” A review of a cardiology consult note for patient #1, dated 1/25/24, showed: “Chief Complaint: Dizziness, bradycardia ...Current Assessment and Plan:...63 yo m was admitted yesterday night with dizziness for 3 days. He was found to have 2:1 AV block with ventricular response in the 30ies.[sic] Overnight he developed a high degree AV block with pauses up to 6-7 seconds. Plan to place a temporary pacemaker now and to evaluate for permanent pacemaker implant in AM. ...” Review of a facility procedure titled, “After Hours Coverage” showed: “Purpose: Ensure appropriate healthcare access and coverage for all home patients after normal facility operating hours. Supportive Data: ...The facility must provide home dialysis patients access to resources and assistance 24 hours/day, 7 days/week. This may be through a call system which can be reached by the patient/family/helper by phone, beeper, answering service or similar arrangement. The facility must provide information to all home patients, regarding who to call and how to obtain emergency medical care when away from the dialysis facility. The patients should be able to contact a call service for a responsible staff member, physician, or on call staff for dialysis-related emergencies 24 hours a day, 7 days a week...””

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to revise the Emergency Preparedness plan within the last two years. This deficient practice had the potential to affect all staff and patients receiving services at the facility. Findings include: A review of the facility’s “Emergency Disaster Plan,” with an effective date of November 15, 2017, and revisions effective 3/4/19, 11/29/19, and 4/16/21. The reviewed “Emergency Disaster Plan,” failed to show an evaluation and update had occurred within the last two years. During an interview on 12/19/23 at 8:30 a.m., staff member B stated he did not document the revision he had made to the Emergency Preparedness plan.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to sustain the prescribed dose of dialysis for 1(#2) of 10 sampled patients. This deficient practice had the potential to cause harm to the affected patient. Findings include: A review of patient #2’s flow chart, dated 12/11/23, showed a Blood Flow Rate (BFR) order for 350 and a Dialysate Flow Rate (DFR) order for 600. Time stamps of 10:56 a.m., 11:00 a.m., 11:30 a.m., and 12:00 p.m., showed a BFR of 450 and a DFR of 700, resulting in one hour and four minutes of increased flow rate. A review of patient #2’s “Current Hemodialysis Orders”, undated, showed arterial and venous needle size of 16 gauge. A review of a facility document titled, “CANNULATION OF THE NEW AV FISTULA”, dated February 2019, showed; “Purpose: To successfully cannulate new arteriovenous fistulas to prevent infiltration. ... RECOMMENDED: It is important to match needle gauge to blood flow rate. Recommended BLOOD FLOW RATE NEEDLE GAUGE Note: These are minimum recommended gauges for the stated BFR settings. Larger needles, when feasible will reduce (make less negative) pre-pump arterial pressure and increase delivered blood flow. PROCEDURE STEPS <300 ml/min 17-gauge 300 - 350 ml/min 16-gauge >350 - 450 ml/min 15-gauge >450 ml/min 14-gauge.” During an interview on 12/19/23 at 3:20 p.m., staff member A stated, “That’s high for a 16-gauge needle and she ran at that for over an hour. That was a mistake.””

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 46400 Based on interview and record review, the facility failed to include peritonitis and exit site infections of PD catheters in their QAPI documentation. This deficient practice led to peritonitis rates being undocumented and had the potential to affect all peritoneal dialysis patients. Findings include: Review of the facility infection control summary dated 6/1/23 - 12/18/23, showed the facility had: June 2023 - one episode of peritonitis and one exit site infection, July 2023 - two exit site infections, September 2023 - three exit site infections, October 2023 - two episodes of peritonitis and one exit site infection, November 2023 - one episode of peritonitis, and December 2023 - two exit site infections. Review of the facility QAPI minutes, dated June 2023 - November 2023, showed no documentation of these infections in the correlated months meetings. During an interview on 12/20/23 at 1:00 p.m., staff member A stated there were notes in the QAPI binder for PD in the early part of the year, but the notes stopped once the previous PD nurse started her position. Staff member A stated the previous PD nurse had not been educated on entering the infections as incidents so they would show up in QAPI. She stated the medical director was aware of the infections and had questioned why they weren’t showing up in the data.”

“PQ-SELF/HOME TRG RN-12 MO RN+3 MO MODALITY CFR(s): 494.140(b)(2) (2) Self-care and home dialysis training nurse. The nurse responsible for self-care and/or home care training must- (i) Be a registered nurse; and (ii) Have at least 12 months experience in providing nursing care and an additional 3 months of experience in the specific modality for which the nurse will provide self-care training. This Standard is not met as evidenced by: 46400 Based on interview and record review, the facility failed to have an experienced home care training nurse. This deficient practice resulted in new patients being unable to be trained for home modalities, and instead started on in-center hemodialysis. Findings include: Review of the facility staff list showed there was an open position for a peritoneal dialysis nurse as of December 2023. During an interview on 12/20/23 at 10:30 a.m., staff member G stated she was covering the peritoneal dialysis patients in the interim. Staff member G stated her background was in hemodialysis. During an interview on 12/20/23 at 1:0 p.m., staff member A stated there were patients who wanted to do peritoneal dialysis, including one with a catheter already placed, but they were unable to start the home training due to the lack of an experienced peritoneal dialysis nurse.”